Acute Coronary Syndrome Emergency Department Updated Jan. 2017
Goals and Objectives To reduce mortality and morbidity for people who have cardiovascular disease, with a focus on those who experience an ST Segment elevation MI, through a systematic approach to reduction of time from identification to reperfusion.
ED Priority It is critical that basic life support (BLS) and advanced cardiovascular life support (ACLS) providers who care for ACS patients in the out-of-hospital setting and emergency department (ED) be aware of the principles and priorities of assessment and stabilization.
Definition of ACS Acute myocardial infarction (AMI) and unstable angina (UA) are part of a spectrum of clinical disease identified as acute coronary syndromes (ACS). The common pathophysiology is a ruptured or eroded atherosclerotic plaque.
Early Diagnosis of ACS Early Care : Recognize & Respond Often mild symptoms, usually normal activity Late Care : Obvious Emergency & Respond Incapacitating pain, diminished activity Too Late Care: Critical Emergency & Respond Unconscious, CPR, Defibrillation, Probable death 85% of heart damage takes place within the FIRST TWO HOURS. Early Care is better care!
Pathophysiology of Acute MI A result of occlusion of arterial flow to the myocardium. Occlusion occurs via spasm, blood clot or stenosis. Ischemia, injury and necrosis can occur.
Risk Factors CAN T Change Age Gender Race Family History CAN Change Smoking Diabetes Obesity High Blood Pressure High Cholesterol
What are the Signs and Symptoms? Chest pain or discomfort, which may or may not involve pressure, tightness, or fullness in the chest Discomfort or pain in both arms, jaw, neck, back, or stomach Shortness of breath Feeling dizzy, lightheaded, or fainting Nausea with or without vomiting Sweating
Remember... Signs can show up days or weeks before a heart attack Not everyone complains of chest pain
Age Differences in ACS Symptoms ACS becomes progressively more common with increasing age. In persons aged 40-70, ACS is diagnosed more often in men than women. After age 70, men and women are affected equally. The elderly Unusual fatigue Shortness of breath Sleep disturbance Anxiety
Gender Specific Differences Men Shortness of breath Cold sweat Chest pain Women Unusual fatigue Sleep disturbance Indigestion Anxiety Nausea
Symptoms of ACS in Diabetics Symptoms may present only as fatigue, weakness or shortness of breath. Maintain a high index of suspicion for ACS when evaluating elderly, women and diabetics.
Other Possible Causes of Chest Pain Aortic dissection Pneumothorax Pericarditis Pulmonary embolus Esophageal rupture Ischemia/rupture of an intraabdominal organ Pain that is not typically associated with ACS Is sharp, stabbing, especially with coughing Is primarily in the mid to lower abdomen Worsens on movement of the chest or arms Occurs in very brief twinges Radiates to the lower extremities Is easily localized to one small area (Patients with these types of pain may still have ACS.)
Goals of Therapy for ACS Reduce the amount of myocardial necrosis that occurs with MI. Prevent major adverse cardiac events: death, nonfatal MI, and need for urgent revascularization. Treat acute, life-threatening complications of ACS VFib, VTach, unstable tachycardias, symptomatic bradycardias.
Time is MUSCLE! Within 5-10 seconds of a heart attack, EKG changes will be seen. Within 20 minutes of a heart attack cardiac enzymes will be elevated. Within 2 hours, permanent damage to the heart will have occurred.
ED Assessment Ideally within 10 minutes of ED arrival, providers should obtain a targeted history, obtain a 12 Lead EKG and give to ED attending physician. Targeted history includes: risk factors for ACS associated signs and symptoms prior cardiac history factors that may preclude use of a fibrinolytic
ED Treatment of ACS (<10min) Start continuous cardiac monitoring O2 as needed to keep SaO2 > 94% Establish IV access, obtain blood for labs: initial cardiac marker levels, electrolyte and coagulation studies Aspirin 324 mg chew (if not given by EMS) Nitroglycerin sublingual Morphine IV (if pain not relieved by NTG) Obtain portable CXR ( <30 minutes)
EKG Basics
Obtain a 12-Lead EKG
The normal ECG tracing
EKG changes: Ischemia Baseline
ECG changes: Injury ST segment elevation of greater than 1 mm in at least 2 contiguous leads. Heightened or peaked T waves
Evolving MI Normal ST Elevation Q-Wave Q-Wave, T-wave inversion
EKG presentation EKG presentation of ACS encompasses STsegment elevation myocardial infarction (STEMI), ST-segment depression, new left bundle branch block (LBBB) and nondiagnostic ST-segment and T-wave abnormalities. A non-st-segment-elevation myocardial infarction (NSTEMI) is diagnosed if cardiac markers are positive with nonspecific EKG s.
Diagnosis of STEMI The EKG is the front-line diagnostic tool in a STEMI It is the first thing done and only thing needed if positive It can diagnose a STEMI by measuring the electrical activity of the heart. Different leads in an EKG can show the different areas of the heart affected by a blockage.
Is this a STEMI? Using the EKG is vital to a rapid identification of patients with STEMI (ST elevation MI) Cardiologists will stratify into low and high risk groups All patients with STEMI and symptom duration of <12 hours are candidates for reperfusion therapy with either fibrinolysis or PCI (percutaneous coronary intervention). Provide PCI within 90 minutes of arrival. AUMC uses PCI as its primary intervention If PCI is not available the goal is to administer fibrinolytics within 30 minutes of arrival.
Critical Care Nurses Symptomatic patients or those with identified ST elevation MI will have EKG repeated every 10 minutes or as directed by physician. Perform Right Sided EKG on any patient with ST elevation or as directed by physician. Document and report abnormal EKG findings, elevated CK-MB and Troponin I results. Complete chest pain registry for quality improvement.
Right Sided EKG Right ventricular MI occurs 40% of the time with inferior MI. Significance: usually larger area of infarct involving both ventricles. Pt may become hypotensive with Nitroglycerin.
Cardiac Biomarkers Obtain Point of Care Troponin I during initial evaluation. Elevated troponin I correlates with an increased rate of death, increased thrombus burden and microvascular embolization. Therapeutic decisions and reperfusion therapy should not be delayed pending results of these tests. Obtain a troponin 3 hrs from baseline (or from time of symptom onset if known), then 6 hours from baseline or symptom onset. Negative Serial Troponins rule out NSTEMI and STEMI.
AUMC Code STEMI Process Pt with identified STEMI: (by triage EKG or EKG done prior to arrival) Cath Lab notification: physician will call ECC at #560 with request to alert Cath Lab for Code STEMI Patient placed in Critical Pod; IV and labs obtained Aspirin 324 mg PO If time permits, prep bilateral groins with clippers Secure patient belongings with family or clerk
Cath Lab Preparation Consent for Cardiac Catheterization (completed by cardiology) Consider Heparin Consider Plavix Consider Integrilin Goal is Door to Balloon in < 90 minutes Pt disrobed and in gown (glasses and dentures are OK. Contact lenses must be removed) Voided/catheterized If time permits, prep bilateral groins with clippers Clerk will make extra pt stickers and copy of chart To cath lab on stretcher as soon as possible
Additional ACC/AHA Class I Recommendations For STEMI/new LBBB: Prepare for PCI. Start adjunctive therapy (do not delay reperfusion) Consider B-Adrenergic blockers Consider Clopidogrel (Plavix) Heparin For Unstable Angina or NSTEMI: Start adjunctive therapy Nitroglycerin Consider B-Adrenergic blockers Consider Clopidogrel Heparin Glycoprotein IIb/IIIa inhibitor (Integrilin)
Class I recommendations cont. For non-diagnostic changes in ST segment or T wave/low risk unstable angina: Consider admission to ED Observation Unit Follow serial cardiac markers Repeat EKGs; continuous cardiac monitoring Consider stress test
Stress Testing It is reasonable for patients with possible ACS who have normal serial ECG s and cardiac Troponin to have a treadmill, stress myocardial perfusion imaging, or stress echocardiography before discharge OR within 72 hours after discharge.
Dysrhythmias
Summary
Patient Education Education starts on admission of patient Signs and symptoms of recurrence When to call 911 (do not drive) Medications Importance Purpose, dose, and side effects Annual flu vaccine Diet, including cholesterol management Weight loss Exercise Lifestyle modifications Smoking cessation Importance of physician follow-up
References ECC Guidelines 2015; Part 9: Acute Coronary Syndromes; Web-based Integrated 2010 & 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Society of Cardiovascular Patient Care (2015). Retrieved from http://www.scpcp.org/index.aspx Amsterdam, E. A., Wenger, N. K., Brindis, R. G., Casey Jr, D. E., Ganiats, T. G., Holmes Jr, D. R., &... Zieman, S. J. (2014). 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 130(25), e344-426. doi:10.1161/cir.0000000000000134